Appeal & Grievance Intake Coordinator
Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. BCBSAZ offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.
Position is remote however candidate must reside in Arizona.
Performs triage (intake, classification, case file setup and assignment) of Medicare Part C and D grievances and appeals; provides administrative, clerical, and other related support to the Grievance and Appeals (G&A) staff; establishes, maintains, and monitors grievance and appeal workload tracking and workflow processes; assists with maintaining regulatory compliance, timeliness requirements and ensuring accuracy standards are met; completes day-to-day operational tasks assigned according to defined processes and procedures; prepares G&A case file folders and assists with tracking and maintaining G&A case records and files; and assists with collecting and reporting G&A related performance and regulatory data.
Required Work Experience
- 2 years of experience in a Medicare Advantage (Part C) and Prescription Drug Benefit (Part D) insurance plan and/or other managed care organization.
- High school diploma or GED in general field of study.
Preferred Work Experience
- 2 years of additional experience, including working knowledge of CMS Managed Care Manual Chapter 13 - Beneficiary Grievances, Organization Determinations, and Appeals and CMS Prescription Drug Benefit Manual Chapter 18 - Part D Enrollee Grievances, Coverage Determinations, and Appeals, knowledge of healthcare billing and claims adjudication processes
ESSENTIAL job functions AND RESPONSIBILITIES
LEVEL I (Grade 9)
- Receive, sort, classify, prioritize, manage, and distribute inbound G&A mail, fax, inter-office, and other correspondence according to policies and procedures, the CMS Managed Care and Prescription Drug Benefit Manuals, and other regulatory and procedural rules, guidelines and timeframes.
- Prepare and assign individual case files to the appropriate G&A staff, continuously update tracking logs, databases, and reports, monitor and manage case status, timelines, statistics, regulatory compliance and performance as required.
- Prepare and mail, fax, inter-office, and other outbound correspondence.
- Coordinate with enrolled members and providers submitting grievances and appeals to obtain additional information or clarification as required.
- Coordinate case files with G&A Staff (administrative evaluation of timely filing, claim payments, insufficient information, etc.), Quality Management staff (quality of care issues) Medical Directors (clinical evaluation of covered services, appropriate level of care, medical necessity, quality of care, etc.) and/or the Chief Medical Officer (clinical evaluation of covered services, appropriate level of care, medical necessity, quality of care, etc.) as required.
- Assist in the preparation and submission of cases to the Independent Review Entity (IRE), as required.
- Receive and coordinate Administrative Law Judge (ALJ), Medicare Appeals Council (MAC), and Federal District Court cases with the G&A staff, Medical Director, Legal, and other departments as required.
- Provide information regarding rights and responsibilities to enrolled members, providers, and other QHP departments as outlined in the Medicare Managed Care Manual.
LEVEL 2 (Grade 10)
- Meeting and exceeding the published department production standards.
- Meeting and exceeding the published department quality standards.
- Full use and knowledge of all research tools (Processing Manual, Meeting Minutes, Department Memos, and Training Material).
- Maintain awareness of legislation, CMS website/instructions that impact Grievance and Appeals
- Be a positive influence on the team culture
- Actively participate in Team meetings, vocalizing opportunities for process improvement and team knowledge share.
- Identify substandard performance by automated processes or software applications
- Actively seeks out opportunities to help others
- Work independently, demonstrating resilience in overcoming obstacles and barriers
LEVEL 3 (Grade 11)
- Obtain mastery in all workflows identified in Level 1 and support in the day-to-day operation of Grievance & Appeals
- Periodically develop and lead content during Team meetings
- Ability to train, display coaching skills
- Troubleshoot any issues with requestor to achieve ultimate efficiency and desired output
- Identify, document, and take ownership over identified automated process or software application issues. Submitted Serving Blue tickets and assisting the assigned technician with troubleshooting problems until the issue is resolved
- Active participant in all regulatory audits
- Be known as a SME in your Functional Unit
- Coverage for individuals or areas of need within the Department
- Provide Quality Assurance of others’ work, provide feedback in a meaningful and constructive way.
- Obtain proficiency in Microsoft Office
LEVEL 4 (Grade 12)
- Develop and maintain relationships with internal customers, colleagues and supply vendors for optimum business partnering results
- Assumed leadership role in Functional Unit audits
- Prioritize work to manage multiple priorities during peak times
- Leadership role with stakeholders and customers
- Advanced skill with operational process flows and associated technology
- Manage inventory and expected business SLAs
- Actively seeks out special projects for Leadership experience
- Ownership and accountability of timely response to regulatory inquiries
Required Job Skills
- Math, communications and business skills normally demonstrated by a high school degree or equivalent.
- Intermediate PC user, including Microsoft Word, Excel, Outlook, Power Point, and Adobe Acrobat Pro.
- Intermediate skill using office equipment, including copiers, fax machines, scanners and telephones.
Required Professional Competencies
- Maintain confidentiality and privacy as outlined by HIPAA.
- Strong critical thinking skills.
- Must possess highly developed interpersonal skills and communications skills, with a strong customer service orientation, and practice interpersonal and active listening skills to achieve customer satisfaction.
- Compose a variety of business correspondence
- Interpret and translate policies, procedures, programs and guidelines
- Strong investigative and analytical research skills
- Navigate, gather, input and maintain data records in multiple system applications
- Follow and accept instruction and direction
- Establish and maintain working relationships in a collaborative team environment
- Organizational skills with the ability to prioritize tasks and work with multiple priorities
Required Leadership Experience and Competencies
Preferred Job Skills
Preferred Professional Competencies
Preferred Leadership Experience and Competencies
BCBSAZ does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.
Thank you for your interest in Blue Cross Blue Shield of Arizona. For more information on our company, see azblue.com. If interested in this position, please apply.